Carotid artery occluding apparatus with first, second and third occluding balloons

ABSTRACT

An apparatus and method for preventing stroke by occluding blood flow through the carotid arteries and a left subclavian artery of a patient is provided. The apparatus has a first occluding catheter that carries a first occluding balloon that has an inflated configuration that occludes one of the carotid arteries. The apparatus also includes a second occluding catheter that carries a second occluding balloon that has an inflated configuration that occludes the other one of the carotid arteries. A third occluding balloon is present, that could be on an insertion device, that may occlude the left subclavian artery.

CROSS REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of and is a continuation-in-part application of U.S. application Ser. No. 15/431,814 filed on Feb. 14, 2017 and entitled “Carotid Artery Occluding Apparatus with First and Second Occluding Balloons. U.S. application Ser. No. 15/431,814 is a divisional application of and claims the benefit of U.S. application Ser. No. 13/941,756 filed on Jul. 15, 2013 that issued on Mar. 21, 2017 as U.S. Pat. No. 9,597,084, and entitled “Carotid Artery Occluding Apparatus with First and Second Occluding Balloons.” U.S. application Ser. No. 13/941,756 is a non-provisional application that claims the benefit of U.S. provisional application Ser. No. 61/672,706 filed Jul. 17, 2012 and entitled “Carotid Artery Occluding Apparatus with First and Second Occluding Balloons.” The present application is also a non-provisional application that claims the benefit of U.S. provisional application Ser. No. 62/692,662 filed Jun. 30, 2018 and entitled “Carotid Artery Occluding Apparatus with First, Second and Third Occluding Balloons.” U.S. application Ser. Nos. 15/431,814; 13/941,756; 61/672,706; and 62/692,662 are incorporated by reference herein in their entireties for all purposes.

FIELD OF THE INVENTION

The present invention relates generally to devices and methods for the prevention of stroke. More particularly, the present application involves an apparatus that has two occluding balloons that are inserted into the circulatory system of the patient to block blood flow, and hence emboli, through the carotid arteries and if needed subclavian arteries during performance of an emboligenic procedure to prevent emboli from passing through the carotid arteries and potentially vertebral arteries and causing stroke.

BACKGROUND

Intraoperative embolic stroke is one of the most dreadful complications of cardiac, aortic and vascular procedures, diagnosed in 1-22% of patients undergoing cardiovascular surgery. Even more frequently, in up to 70% of cases, patients undergoing heart, valve, coronary artery bypass and aortic surgery experience subclinical embolic events as recorded by transcranial Doppler and MRI. These embolic events lead to cognitive impairment and disability and have a significant impact on patients' recovery.

The main sources of cerebral emboli and stroke in this setting reside in the heart, heart valves, thoracic aorta, and great vessels when these structures are intervened thereon. Even simple cardiac catheterization with an endovascular catheter can induce microtrauma of the atherosclerotic thoracic aorta leading to formation of embolic particles with subsequent embolic brain injury ranging from latent ischemic foci to a massive or even fatal stroke.

Multiple devices are known that attempt to prevent embolization of the carotid arteries during endovascular and cardiac interventions. These anti-embolic devices, however, have not received wide acceptance in surgery of the heart, heart valves and thoracic aorta due to their complexity and invasive character with the risk of additional trauma to the inner vessel wall resulting in a high risk to benefit ratio. Known devices require insertion of additional hardware into the arterial system or aorta, a procedure that is known by itself to be associated with all classical risks of endovascular intervention, including aortic dissection, bleeding, thrombosis, and carotid cerebral embolization and stroke. One known intra-aortic filter device that is inserted into the ascending portion of the thoracic aorta via an aortic cannula to capture potential embolic material released from the heart and aortic wall during heart surgery was found to be quite difficult to implement and was reported to be associated with major trauma to aortic wall and acute aortic dissection.

Another such device for preventing emboli into the cerebral circulation includes a porous deflector/intra-aortic shield that captures or diverts potential emboli into the distal vasculature. A yet additional device has also been proposed for use during aortic valve surgery and is an intra-aortic filter catheter that captures emboli during this procedure. It has been established that intravascular filters are not able to capture emboli smaller than the pore size of the available devices (currently 60-140 μm) resulting in cerebral microembolization. Embolization may also occur due to poor apposition of the filter to the aortic or carotid arterial wall.

Furthermore, the placement of the filter by itself may produce cerebral emboli. For example, the mere passing of a guide wire into a carotid artery generates approximately 40,000 microemboli, with a significant percentage of small, less than 60 μm, particles that are not retained by standard filters. Therefore, in spite of multiple innovations in the field of anti-embolic devices, the problem of cerebral emboli and stroke during cardiovascular surgery is far from being resolved.

It is known to use balloon occlusion catheters for the prevention of embolic stroke. In this regard, the balloon occlusion catheter is placed inside of one of the carotid arteries when a procedure, for example carotid angioplasty and stenting, is conducted on the carotid artery in question. Although capable of preventing stroke when a single carotid artery is operated upon, this device cannot work to prevent stroke during procedures on the heart and aorta, endovascular or open, and cannot provide for bilateral occlusion. This device cannot simultaneously occlude both the left and right carotid arteries to prevent flow simultaneously through both of these arteries, and thus cannot prevent stroke should emboli flow into the non-blocked carotid artery.

Also, the design of known endovascular devices did not address the issue of specific orientation of balloons in carotid arteries. By failing to address this issue, the methods cause an increase in the amount of time and effort needed to make the placement and likewise cause a safety concern.

Further, known endovascular carotid occluding devices require a guide wire to be inserted into the carotid arterial system. This procedure by itself is known to induce carotid trauma and cause the formation of cerebral emboli and resultant stroke. Still additionally, prior endovascular carotid occluding devices are not capable of reducing arterial flow through both right and left vertebral arteries, either at the same time or individually. This deficiency may allow emboli to enter vertebral circulation and cause stroke.

Still further, known systems are not capable of interrupting the flow, if needed, to both vertebral arteries for the period of time when emboli can enter cerebral circulation. Known systems also risk trauma to the carotid artery wall and allow for subsequent cerebral emboli. As such, there remains room for variation and improvement within the art.

BRIEF DESCRIPTION OF THE DRAWINGS

A full and enabling disclosure of the present invention, including the best mode thereof, directed to one of ordinary skill in the art, is set forth more particularly in the remainder of the specification, which makes reference to the appended Figs. in which:

FIG. 1 is a front view of a patient with emboli in the heart and ascending thoracic aorta with subsequent propagation of emboli into both carotid arteries with the source of emboli being diseased aorta, aortic valve and the heart.

FIG. 2 is a front view of the circulatory system with a first occluding balloon in an innominate artery, a second occluding balloon in a left carotid artery and a third occluding balloon in a left subclavian artery with a common catheter shaft at the proximal segment of the catheter creating an option of a trifurcated occluding balloon catheter.

FIG. 3 is a front view of the circulatory system with a first occluding balloon in a right carotid artery, a second occluding balloon in a left carotid artery, and a third occluding balloon in a left subclavian artery.

FIG. 4 is a front cross-sectional view of a first occluding catheter.

FIG. 5 is a front cross-sectional view of a second occluding catheter.

FIG. 6 is a cross-sectional view taken along line 6-6 of FIG. 4 with the additional cross-sectional half added.

FIG. 7 is a cross-sectional view taken along line 7-7 of FIG. 4 with the additional cross-sectional half added.

FIG. 8 is a cross-sectional view taken along line 8-8 of FIG. 5 with the additional cross-sectional half added.

FIG. 9 is a cross-sectional view taken along line 9-9 of FIG. 5 with the additional cross-sectional half added.

FIG. 10 is a side view of an insertion device with a built-in occluding balloon.

FIG. 11 is a cross-sectional view taken along line 11-11 of FIG. 10.

FIG. 12 is a perspective view of an apparatus that includes an occluding insertion device and two occluding catheters.

FIG. 13 is a cross-sectional view taken along line 13-13 of FIG. 12.

FIG. 14 is a perspective view of an insertion device with an occluding balloon.

FIG. 15 is a front view of the circulatory system that shows placement of an insertion device with the aid of a guide wire.

FIG. 16 is a front view of the circulatory system with two occluding catheters with uninflated occluding balloons introduced through the insertion device carrying an uninflated occluding balloon.

FIG. 17 is a front view of the circulatory system with three inflated occluding balloons, positioned in the right carotid, left carotid and left subclavian arteries.

FIG. 18 is a front view of the circulatory system with three inflated occluding balloons positioned in the innominate artery, left carotid artery and left subclavian artery, with an alarm system and pressure supply.

FIG. 19 is a front view of the circulatory system with multiple inflated occluding balloons inserted via contralateral upper extremities.

FIG. 20 is a front view of the circulatory system with the vessel occluding apparatus inserted via the left femoral artery.

FIG. 21 is a side view of the distal end of an insertion device in accordance with one exemplary embodiment.

FIG. 22 is a top view of FIG. 21.

Repeat use of reference characters in the present specification and drawings is intended to represent the same or analogous features or elements of the invention.

DETAILED DESCRIPTION OF REPRESENTATIVE EMBODIMENTS

Reference will now be made in detail to embodiments of the invention, one or more examples of which are illustrated in the drawings. Each example is provided by way of explanation of the invention, and not meant as a limitation of the invention. For example, features illustrated or described as part of one embodiment can be used with another embodiment to yield still a third embodiment. It is intended that the present invention include these and other modifications and variations.

It is to be understood that the ranges mentioned herein include all ranges located within the prescribed range. As such, all ranges mentioned herein include all sub-ranges included in the mentioned ranges. For instance, a range from 100-200 also includes ranges from 110-150, 170-190, and 153-162. Further, all limits mentioned herein include all other limits included in the mentioned limits. For instance, a limit of up to 7 also includes a limit of up to 5, up to 3, and up to 4.5.

In our previous designs Applicant described a system for cerebral protection based on one or two occluding balloons, whereas in this application it is disclosed a new aspect of cerebral protection from emboli using a three (3) balloon system with a third balloon optionally integrated into the vascular introducer sheath resolving a problem of occlusion of the proximal segment of the subclavian artery that is paramount for prevention of the flow of emboli into the vertebral arterial system. The present invention provides for an apparatus 10 that has a first occluding catheter 16 that carries a first occluding balloon 18, a second occluding catheter 20 that carries a second occluding balloon 22, an optional third occluding catheter 21, carrying a third occluding balloon 120, and an insertion device 58, carrying an occluding balloon 122 that could be the third occluding balloon 122. The occluding catheters 16, 20 and 21 can be introduced into the circulatory system 92 of a patient as a single trifurcated catheter with a common single shaft 124 or separately—through an insertion device 58 and the occluding balloons 18, 22 and 120 can be inflated in order to occlude blood flow through the right carotid artery 12, the left carotid artery 14 and the left subclavian artery 28 at the same time. This may occur during a surgical procedure that releases emboli 90 that would otherwise flow through the carotid arteries 12, 14 and the vertebral arteries 150, 152 that come off the subclavian arteries 26 and 28 and cause stroke or other damage to the patient. Blockage of both carotid arteries 12, 14 and subclavian arteries 26, 28 causes the emboli 90 to be routed away from the brain primarily or fully down through the descending aorta 98. The apparatus 10 may include an insertion device 58 that can first be placed into the circulatory system 92 so that the occluding catheters 16, 20 can be subsequently inserted and more easily positioned within the circulatory system 92. An insertion device 58 may carry a built-in occluding balloon 122, designated to occlude a subclavian artery 26, 28, on the side of insertion of the device 58 in order to prevent the entry of emboli 90 into ipsilateral vertebral arterial system, carrying blood to the posterior portion of the brain.

With reference to FIG. 1, a front view of a patient is shown in which emboli 90 are transferred from the aortic arch 96 into the carotid arteries 12, 14 and subclavian arteries 26, 28. The emboli 90 that enter the carotid arteries 12, 14 and subclavian arteries 26, 28 can then be transferred into the cerebral circulation causing stroke of the patient. The emboli 90 may be fragments of atherosclerotic plaque 104 of the ascending aorta 96 that become dislodged during manipulation of the ascending thoracic aorta 102. Also shown in FIG. 1 is calcification of the aortic valve 100 and intracardiac emboli 90 of the heart 94 that can also be the origin of emboli 90 eventually present in the carotid arteries 12, 14. The intracardiac emboli 90 may include air, gas, thrombi and atherosclerotic materials. Although all of the various emboli 90 in the heart 94, aortic arch 96, ascending aorta 102, and aortic valve 100 need not be present in all instances, they are all shown in FIG. 1 for sake of example.

Trauma to the heart 94, aortic valve 100 and aortic structures during placement and removal of items such as aortic clamps and electrophysiological instruments, along with manipulations such as coronary artery bypass grafting, aortic and mitral valve replacement, catheter ablation, endovascular grafting of the aorta 96, balloon valvuloplasty percutaneous implantation of the aortic or mitral valves, endovascular manipulations on the aorta 96, aortic branches and the heart 94 may give rise to the presence of emboli 90 in the carotid arteries 12, 14 and subclavian arteries 26, 28, and the vertebral arteries 150, 152. Critical moments of the aforementioned procedures (for example during the aortic cross clamp manipulation, percutaneous aortic and mitral valvuloplasty or valve implantation, coronary interventions, endovascular grafting of the aorta 96 and its branches, and endovascular procedures on the aorta 96) may cause emboli 90 to form and cause stroke and are referred to as “emboligenic” events.

FIGS. 2 and 3 disclose exemplary embodiments of the invention in which the first, second and third occluding balloons 18, 22 and 120 are simultaneously inflated. The second occluding balloon 22 is shown in the inflated position within the left carotid artery 14 and occludes the left carotid artery 14. The first occluding balloon 18 is shown positioned within the innominate artery 24 in FIG. 2 and occludes both the right carotid artery 12 and the right subclavian artery 26, and a third occluding balloon 120 is positioned within the left subclavian artery 28 and occludes to flow to the left vertebral artery 150 as the left vertebral artery 150 is downstream from the third occluding balloon 120. As such, the left vertebral artery 150 may be occluded even though the third occluding balloon 120 or no portions of the apparatus 10 are within the left vertebral artery 150. The first occluding balloon 18 in the innominate artery 24 likewise occludes flow to the right vertebral artery 152 that is downstream therefrom and does not have any components of the apparatus 10 therein. As depicted in FIG. 2 all three occluding balloons 18, 22, 120 may have a unified shaft 124 that is inserted into the peripheral artery of the arm as a single prepackaged unit, or may be inserted through an insertion device 58.

Alternatively, in FIG. 3 the first occluding balloon 18 is in the inflated configuration and is located in the right carotid artery 12 occluding the right carotid artery 12 but not occluding the right subclavian artery 26. In both configurations, all potential emboli 90, released due to manipulations on atherosclerotic calcified plaques 104 of the ascending aorta 102 or from other sources as previously discussed, will be diverged downstream from the cerebral circulation into the descending aorta 98, thus protecting the patient from embolic stroke.

The temporary interruption of flow at the level of the proximal carotid arteries 12, 14 and subclavian arteries 26, 28 leads to the divergence of blood flow, as indicated by arrow 116, and carries all potential cerebral emboli 90 into the distal aorta 98 and femoral arteries 110, 112. With reference to FIG. 2, the position of the first occluding balloon 18 can be adjusted by placing it right at the bifurcation of the innominate artery 24 in order to completely interrupt the arterial inflow to the right carotid artery 12 and the right subclavian artery 26. This placement may protect not only the right carotid artery 12, but also the right vertebral 152 circulation from emboli by virtue of blocking the arterial inflow to these vessels through the right subclavian artery 26. In both FIGS. 2 and 3, the first and second occluding catheters 16, 20 are introduced through the left subclavian artery 28. The size of the catheters 16, 20 may be such that they fill the left subclavian artery 28 and block blood flow through the left subclavian artery 28 thus preventing emboli 90 from entering the left vertebral 150 circulation. Such blocking effect may be enhanced by adding an occluding balloon 122 to the introducer device 58 as shown in FIGS. 10-16.

The first occluding catheter 16 is shown in greater detail with reference to

FIGS. 4, 6 and 7. The first occluding balloon 18 is shown in the inflated configuration. The first occluding catheter 16 has a first occluding catheter shaft 30 that may be of any length, diameter, shape, or size. The first occluding catheter shaft 30 can define a first inflation channel that extends from a first proximal inflation port 34 at a proximal end of the shaft 30 to a location close to or at the first occluding balloon 18. A first occluding balloon opening 36 is defined by the first occluding catheter shaft 30 and places the first inflation channel 32 into fluid communication with the interior of the first occluding balloon 18. A fluid pressure sources such as a syringe or pump can be connected to the first proximal inflation port 34 and actuated in order to force air, liquid, or any other type of fluid through the first inflation channel 32 and into the first occluding balloon 18 to place the first occluding balloon 18 into the inflated configuration shown in FIG. 4. Once one desires to deflate the first occluding balloon 18, the pressure may be released or the fluid may otherwise be withdrawn from the first occluding balloon 18 back in the proximal direction through the first inflation channel 32. The first occluding balloon 18 may have any size or shape and can be made of a material resilient yet strong enough to allow for repeated inflation and deflation.

The first occluding catheter shaft 30 may also define a first pressure measurement channel 38 that can extend completely through the shaft 30 from its proximal end to its distal end. The first pressure measurement channel 38 may extend from a first proximal measurement port 40 on the proximal end to a first distal opening 42 at the extreme distal tip of the first occluding catheter shat 30. The first pressure measurement channel 38 may be used to measure pressure of the circulatory system 92 at a location distal to the inflated first occluding balloon 18 and thus the pressure of the circulatory system 92 at the first distal opening 42 or just distally past the first distal opening 42. In this regard, a pressure measurement device, for example a manometer 106 can be placed into fluid communication with the first pressure measurement channel 38 by connection at the first proximal measurement port 40 and have access to the pressure of the circulatory system 92 at a location at or distal to the first distal opening 42.

The channels 32 and 38 are shown as being circular in cross-sectional shape, but it is to be understood that they may be variously shaped in accordance with other exemplary embodiments. Also, although shown as having but a single first occluding balloon opening 36, any number of openings 36 may be present in other arrangements. Still further, although shown as having but a single first occluding balloon 18, any number of balloons 18 can exist in other arrangements. For example, from 2-5, from 6-10, or up to 20 occluding balloons 18 may be present on the first occluding catheter 16 in other exemplary embodiments.

A more detailed view of the second occluding catheter 20 is shown in FIGS. 5, 8 and 9. The second occluding catheter 20 includes a second occluding catheter shaft 44 that defines a second inflation channel 46 that extends from a second proximal inflation port 48 to a second occluding balloon opening 50. The second occluding catheter shaft 44 also defines a second pressure measurement channel 52 that extends from a second proximal measurement port 54 to a second distal opening 56. The various components of the second occluding catheter 20 can be arranged in the same manners are those previously discussed above with respect to the first occluding catheter 16 and a repeat of this information is not necessary.

The first and second occluding catheters 16 and 20 may be arranged in the same manner as one another but may be sized differently from one another such that the shafts 30, 44 are different lengths from one another. The diameter, volume and length of the occluding balloons 18, 22 may also vary according to patient's anatomy with the occluding balloon 18, 22 that is to be disposed within the innominate artery 24 being 50-100% longer and larger than the occluding balloon 18, 22 for the occlusion of the left carotid artery 14. In this regard, the first diameter 78 may be 50-100% larger than the second diameter 80. However, in other embodiments, the first diameter 78 may be the same size as the second diameter 80, may be 10-25% larger, 10-25% smaller, 25-50% larger, 25-50% smaller, 50-200% larger, 50-200% smaller, 200-500% larger, or 200-500% smaller in accordance with various exemplary embodiments.

The apparatus 10 may also include an insertion device 58 in certain exemplary embodiments that can function to help properly position the first and second occluding catheters 16, 20 within the circulatory system 92. FIGS. 10 and 11 illustrate one exemplary embodiment of the insertion device 58 that has a shaft that defines 3 channels 60, 66, 72 that are through channels that extend through the insertion device 58 and a third occluding balloon inflation channel 128 that extends through a portion of the insertion device 58. In some embodiments, however, the occluding catheters 16, 18 may be inserted through a single common channel 60. The shaft of the insertion device 58 may define a first occluding catheter channel 60 that extends from an insertion device first proximal opening 62 at the proximal end of the insertion device 58 to an insertion device first distal opening 64 at the distal end of the insertion device 58. The insertion device first distal opening 64 is located at a tapered distal edge of the insertion device 58 and has a cross-sectional shape that is generally oval that has both convex and concave surfaces.

The insertion device 58 may also include a second occluding catheter channel 66 that is also a through channel of the shaft of the insertion device 58 that extends from an insertion device second proximal opening 68 at the proximal end of the insertion device 58 to an insertion device second distal opening 70. The second occluding catheter channel 66 has a cross-sectional shape in the form of an oval. The second occluding catheter channel 66 is shorter in length than the first occluding catheter channel 60 and is located off center from the first occluding catheter channel 60 so that the channels 60 and 66 are not coaxial with one another. The insertion device second distal opening 70 is located at a surface of the insertion device 58 that is angled or tapered such that it is not a flat surface. The tapered distal openings 64 and 70 are designed to create a cradle for occluding balloons to accommodate the occluding balloons 18, 22 in such a way that deflated and/or specifically folded balloons would congruently fit the area of a distal opening 64, 70 to match the outer profile of the insertion device 58 achieving a goal of effortless insertion of the device 58 into patient's artery using a smaller size of the vascular introducer. In some embodiments the occluding balloons 18, 22 may be prepackaged into the distal openings 64, 70 before insertion of the device 58 and then advanced into the innominate 24, carotid 12, 14 and subclavian arteries 26, 28 once the insertion device 58 is positioned in the aortic arch 96 with the distal openings facing directly the orifices of the innominate 24, carotid 12, 14 and subclavian arteries 26, 28. A disclosed distance between the distal openings 64, 70 and an optional distal opening for a catheter 21, carrying an occluding balloon 120 allows for precise positioning of the balloons against the orifices of the innominate, carotid and subclavian arteries. These distance between each pair of these openings have been measured on hundreds of CT angiograms of the aortic arch 96 and was found to be between 0.5 and 5.5 centimeters. Whereas the distance between distal opening 64 and the occluding balloon 122 is disclosed as being in the range of 1.5-10.5 centimeters achieving the goal of standardized catheter positioning, where if at least one of the openings is positioned against a corresponding target artery (24, 14, 28 or 26), the other opening and/or occluding balloon is automatically positioned against the other target artery.

An occluding balloon 122 is built into the insertion device 58 with the distance between the tip of the device (distal opening 64) and location of the distal segment (denoted generally at the cross-section line 11-11 in FIG. 10) of the occluding balloon 122 being between 1.8 centimeters and 5.5 centimeters and the distance between the distal opening 70 and the distal segment (denoted generally at cross-section line 11-11) of the occluding balloon 122 being 1.0-3.5 centimeters. The third occluding balloon 122 is shown inflated in FIG. 10 and is attached to and engages the outer surface of the insertion device 58 and extends in the radial direction beyond the channels 60 and 66.

An insertion device 58 may contain a third occluding balloon inflation channel 128 for inflation of the third occluding balloon 122. Air or other fluid is inserted through the third inflation port 130 and into and through the third occluding balloon inflation channel 128 and out of the third inflation balloon opening 26 to inflate the third occluding balloon 122. However in some embodiments the third occluding balloon 122 may not have to be inflated as it can be created having a certain volume of liquid or gas allowing for occlusion of the subclavian artery 28 upon its insertion. The third occluding balloon 122 is located on and engages the outer surface of the insertion device 58 such that the first and second occluding catheters 16, 20 move through the channels 60 and 66 and thus through the third occluding balloon 122. The pressure measurement channel 72 also extends through the third occluding balloon 122. The third occluding balloon 122 may extend around the entire outer surface of the insertion device 58.

The insertion device 58 also has a pressure measurement opening 132 through which pressure upstream or downstream of the occluding balloon 122 can be measured. For example, the pressure of the left subclavian artery 150 could be measured when the occluding balloon 122 is inflated. A measurement channel 133 extends through the insertion device 58 from the pressure measurement opening 132 back to the port 134 that can be connected to a manometer 106 or other pressure measurement device for pressure measurements. The measurement channel 133 is in fluid isolation from the other channels 60, 66, 72 of the insertion device 58. The pressure measurement opening 132 may be distal to the occluding balloon 122 and proximal to both distal openings 64, 70 in other exemplary embodiments.

The shaft of the insertion device 58 also defines a pressure measurement channel 72 that is a through channel of the insertion device 58 and extends from a pressure measurement proximal opening 74 at the proximal end of the insertion device 58 to a pressure measurement distal opening 76. The pressure measurement channel 72 has a circular cross-sectional shape and is offset from and not coaxial with either the first occluding catheter channel 60 or the second occluding catheter channel 66. The pressure measurement channel 72 can be used for irrigation and pressure measurement distal to the pressure measurement distal opening 76, or in some embodiments it can be used for insertion of a distal occluding catheter 16.

The openings 64 and 70 can be positioned so that they face in a direction that is angled to a direction along the longitudinal axis of the shaft of the insertion device 58. The axis of the openings 64 and 70 are not coaxial with the axis of the shaft of the insertion device, and extend in the same direction as one another such that the openings 64 and 70 open onto a common side of the shaft of the insertion device 58. This arrangement may assist the first and second occluding catheters 16, 20 in being properly positioned in the circulatory system 92.

The first and second occluding catheters 16, 20 may be inserted through the insertion device 58 such that the insertion device 58 is used to position the catheters 16, 20 within the circulatory system 92. With reference to FIGS. 12-14, the first occluding catheter 16 can be introduced through the insertion device first proximal opening 62 and into the first occluding catheter channel 60. The first occluding catheter 16 may be moved relative to the insertion device 58 such that the first occluding balloon 18, that can be uninflated, is moved out of the insertion device first distal opening 64 and out of the channel 60. In a similar manner, the second occluding catheter 20 can be moved through the insertion device second proximal opening 68 and into the second occluding catheter channel 66.

In other embodiments, however, the occluding catheters 16, 20 may be moved only partially out of the insertion device 58 in order to avoid friction related to the passage of the first and second occluding balloons 18, 22 through the channels 60, 66. This is achieved by a congruent design of the distal openings 64, 70 and the respective occluding balloons 18, 22 that when deflated and/or folded during packaging are congruently fit into the distal openings 64, 70 with a filling of the distal openings 64, 70 and thus decreasing the outer profile of the folded occluding balloons 18, 22 to the size similar to dimensions of distal openings 64, 70. This design allows in some embodiments to have occluding balloons 18, 22 of a much larger size as they do not have to be passed through channels 60, 66 and are positioned inside the congruent distal openings 64, 70.

The second occluding balloon 22 may or may not be moved out of the insertion device second distal opening 70 and thus out of the channel 66 depending on the type of the embodiment as described above. The occluding catheters 16, 20 may be located within the insertion device 58, and/or within the oval, semi-oval or pear-shaped distal openings 64, 70 that are amenable to accept a fully compressed, folded and/or packaged balloon into the specifically designed cradle space provided by the distal openings 64, 70 without the need to advance or withdraw the balloons through the channels of catheters 16, 20, 21. As such, the distal openings 64, 70 can be shaped in a manner and of a size that receives the deflated occluding balloons 18, 22 so that the deflated occluding balloons 18, 22 are located at the distal openings 64, 70 and are not moved through the channels 60, 66 when the insertion device 58 is inserted. Instead, the first and second occluding balloons 18, 22 begin at the, distal openings 64, 70 and are moved out of the distal openings 64, 70 to move into their occluding and inflated positions. This cradle at the distal openings 64, 70 can be a pear shaped cross-sectional design, or any design that is not oval in, shape due to the circular cross-sectional shapes of the channels 60, 66 and a possible taper cut at the distal openings 64, 70.

A first syringe 82 can be connected to the first proximal inflation port 34, a second syringe 84 can be connected to the second proximal inflation port 48, and a third syringe 138 can be connected to port 130, or 140 (FIG. 12) connected to inflation channel 128 and the third balloon inflation openings 126 to inflate the third occluding balloon 120 or 122 after the device 58 is inserted to the level of subclavian artery 26, 28. Actuation of the syringes 82, 84 may function to inflate the first and second occluding balloons 18, 22 as previously discussed. In the FIG. 12 embodiment, the occluding balloon 122 on the insertion device 58 can be inflated via air or fluid entering through distal opening 126 from channel 128. Port 130 can be connected to a manometer 106 or other device to measure the pressure in the occluding balloon 122 via the pressure measurement opening 132 through the measurement channel 133. Alternatively, the opening 132, channel 133 and port 130 can be used to inject inflation air or fluid into the occluding balloon 122 to cause its inflation in other embodiments as well. As such, two ports 130, 134 or 140 with their respective openings 126, 132 could be used to effect inflation and/or deflation of the occluding balloon 122.

In other arrangements, a single syringe can be, placed into fluid communication with the ports 34, 48 and 130, 140 and used to inflate all balloons 18, 22, 120, 122 at the same time. In other embodiments this function can be performed using an automated inflation device triggered by a variety of physiological triggers, such as the appearance of emboli 90 or embolic signals in the arteries, alteration of cerebral perfusion, infrared spectroscopy signal, cerebral oximetry, cerebral blood flow or electroencephalogram as depicted in FIG. 18. The first proximal measurement port 40 can be connected to a manometer 106 so that the pressure at the first distal opening 42 can be measured. Similarly, the second proximal measurement port 54 can be connected to the same or different manometer 106 so that the pressure at the second distal opening 56 can be measured. Although not shown in FIG. 12, the pressure measurement proximal opening 74 can be connected to a manometer 106 so that the pressure at the pressure measurement distal opening can be measured.

The space between the insertion device first distal opening 64 and the insertion device second distal opening 70 in the longitudinal/axial direction of the shaft of the insertion device 58 can be selected to correspond to the distance between the innominate artery 24 and the left carotid artery 14 orifice on the inner surface of the aortic arch 96. The distance between the openings 64 and 70 may be selected to roughly correspond to the orifices within the circulatory system 92 that one desires catheters 16, 20 to be inserted upon exiting the openings 64 and 70. The desired spacing of the openings 64 and 70 may be achieved by selecting or creating an introducer device 58 that has dimensions that match the distance between the orifices of the left carotid artery 14 and the innominate artery 24 at the aortic arch 96 as estimated by preoperative CT scan. In some instances, the distance between openings 64 and 70 in the longitudinal/axial direction of the shaft of the insertion device 58 may be between 0.5 centimeters and 5.5 centimeters. Use of properly spaced openings 64 and 70 may achieve safer and easier advancement of the first and second occluding catheters 16, 20 without trauma to the carotid arteries 12, 14 or the aortic arch 96.

With reference to FIG. 15, the insertion device 58 may be inserted via a left arm approach and advanced into the left subclavian artery 28 and into the aortic arch 96 using fluoroscopic control with the third occluding balloon 122 positioned at the level of the subclavian artery 28, while the distal openings 64, 70 are positioned at the level of the innominate artery 24 and the left carotid artery 14. This precise positioning is achieved by a disclosed specific distance between the openings 64, 70 and a third occluding balloon 122 as discussed above. The occluding balloon 122 is not inflated in FIG. 15.

A flexible guide wire 118 may be used for this part of the procedure. However, the use of a guide wire 118 is not needed in other exemplary embodiments, and the insertion device 58 if used may be placed without the aid of a guide wire 118. Further, the use of an insertion device 58 is not needed in other exemplary embodiments. The occluding catheters 16, 20 may be naturally propelled into the target vessel with forward arterial flow thus following the natural direction of the blood stream into the innominate artery 24 and both carotid arteries 12, 14. This feature may be achieved by using highly compliant and flexible material for the construction of the shafts of the catheters 30 and 44.

The portions of the insertion device 58 forming the insertion device first distal opening 64, the insertion device second distal opening 70, as well as occluding balloons 18, 22 may be radiopaque and can be positioned to face the orifices of the left carotid artery 14 and the innominate artery 24 on the aortic arch 96. In addition the third occluding balloon 122 and/or the occluding balloon 120 may be made radiopaque to facilitate their placement into the orifices of the subclavian arteries 26, 28 to protect vertebral arteries 150, 152 from potential emboli. Next, the guide wire 118 if used may be removed. Alternatively, the guide wire 118 if used may be left in place. The guide wire 118 if used may be placed through any of the channels 60, 66 and 72.

With reference now to FIG. 16, the first occluding catheter 16 may not have to be advanced through the insertion device first proximal opening 62, but could be premade as located within the cradle of a distal opening 64 thus being located at the distal opening 64, precluding the need for passing the potentially bulky balloon through the catheter channel 72. In this case once the distal opening 64 is positioned against the ostium of the innominate artery 24, the occluding balloon 18 will be advanced out of its cradle 64 by advancing the shaft of the catheter 16. Similarly, the second occluding catheter 20 may be preloaded into the insertion device channel with the occluding balloon 22 being folded and pre-packaged into the second proximal opening 68. The second occluding balloon 22 can be pushed out of its cradle at the distal opening 70 and advanced into the left carotid artery 14 by virtue of advancing the second occluding catheter shaft 20 through a channel 66 such that the deflated second occluding balloon 22 comes out of the insertion device second distal opening 70, where it was pre-packaged ahead of time. Once the first and second occluding balloons 18 and 22 are out of the insertion device 58 they may be advanced into the vessels that are desired to be occluded. In the exemplary embodiment shown, the first occluding balloon 18 is advanced into the right carotid artery 12 and the second occluding balloon 22 is advanced into the left carotid artery 14, while the third occluding balloon 122 is advanced into the subclavian artery 28. The third occluding balloon 122 is located completely proximal to the distal openings 64, 70 on the insertion device 58.

In the right sided approach a mirror-image embodiment can be used, where the insertion device 58 is inserted via the right arm and positioned with the third occluding balloon at the level of the innominate artery 24 and/or subclavian artery 26, whereas the second occluding balloon 22 may be positioned in the right carotid artery 12 or left carotid artery 14, while a first occluding balloon may be positioned inside the left carotid artery 14, or left subclavian artery 28, thus preventing the entry of emboli 90 into all possible sources of blood inflow to the brain. The process of advancement may be facilitated by partial or complete inflation of the first and second occluding balloons 18, 22 while the first and second occluding catheters 16, 20 remain in the aortic arch 96 to achieve the effect of propulsion of the balloons 18, 22 into the target blood vessels with arterial blood flow. The inflated first occluding balloon 18 may be naturally propelled by arterial blood flow into the innominate artery 24 and if desired the right carotid artery 12, and the inflated second occluding balloon 22 may be carried by arterial blood flow into the left carotid artery 14. In other arrangements, the occluding balloons 18, 22 are not inflated prior to positioning and are only inflated or even only partially inflated once they are positioned within their appropriate arteries 12, 14.

The adequacy of the position of the occluding balloons 18, 22, 120, 122 can be confirmed by fluoroscopy, angiography, and by dampened arterial pressure recorded at the first distal opening 42 and the second distal opening 56 that are located downstream from the areas of occlusion. The ideal position of the first occluding balloon 18 may be at the proximal segment of the right carotid artery 12 or the distal segment of the innominate artery 24, and the best position of the second occluding balloon 22 may correspond to the proximal segment of the left carotid artery 14, while the best position for the third occluding balloon 120, 122 may be the proximal segment of the subclavian artery 26 or 28. Once the occluding balloons 18, 22 are properly positioned they may be deflated and then considered ready for use. The insertion device 58 if used may be present during use of the occluding balloons 18, 22 with the third occluding balloon 120 or 122 inflated at the same time as the balloons 18, 22.

FIGS. 21 and 22 show a portion of the insertion device 58 located at the distal end of the insertion device 58. Although a third occluding balloon 120 or 122 can be included, it is not shown in FIG. 21 or 22. The distal openings 64 and 70 are configured to accommodate the first and second occluding balloons 18, 22 which are deflated, pre-packaged and/or crimped inside the distal openings 18, 22 to facilitate insertion of the insertion device 58 and/or the first and second occluding balloons 16, 20 into smaller arteries. The arrangement of the distal end of the insertion device 58 as illustrated achieves a lower profile which makes it easier to move into smaller access arteries. The design of the distal openings 64, 70 achieves a smaller profile (outer diameter) of the insertion device 58 by making the occluding balloons 18, 22 congruently fit inside a cradle formed by the distal openings 64, 70.

The second occluding balloon 22 located more proximal than the first occluding balloon 18 and extends in its cradle at the distal opening 70 so as to be located vertically higher than a portion of the outer surface of the insertion device 58 distal to the distal opening 70. The occluding balloons 18, 22 may thus extend a portion out of the distal openings 64, 70 when prepackaged, but could be completely within the insertion device 58 in accordance with other embodiments while being transported by the insertion device 58 but before deployment therefrom.

FIGS. 17 shows the apparatus 10 positioned within the circulatory system 92 and used to deflect emboli 90. Right before proceeding with the emboligenic part of surgery or endovascular intervention the first, second and third occluding balloons 18, 22, 122 are inflated using syringes 82, 84, 138 attached respectively to the first proximal inflation portion 34, the second proximal inflation port 68 and the third inflation port 134, 130 or 140 to provide temporary obstruction of arterial blood flow through the right carotid artery 12, left carotid artery 32 artery and the left subclavian artery 28. As a result most of the potential emboli 90, formed secondary to the main intervention on the heart 94, coronary arteries and aorta 96 will be diverted into the distal aorta 98, and peripheral arteries 110, 112. If the right subclavian artery 26 is not blocked by the occluding balloon 122 or by a larger outer diameter of the device 58, emboli 90 may flow through this artery 26. The presence of the insertion device 58 in the left subclavian artery 28 may function to block emboli 90 from flowing through the left subclavian artery 28, however, because some emboli 90 may in fact may flow through the left subclavian artery 28 it would be preferable to inflate the third occluding balloon 122 at the level of the ostium of the left subclavian artery 28.

FIG. 18 shows placement of the first occluding balloon 18 within the innominate artery 24, the second occluding balloon 22 in the left carotid artery 14 and the third occluding balloon 122 into the left subclavian artery 28 The balloons 18, 22, 122 could be variously configured from that disclosed in other embodiments such as by having one of the occluding balloons 18, 22, 122 sized and shaped to be located in both the innominate artery 24 and the right carotid artery 12. Occlusion of the arteries 24, 14 and 28 will cause all emboli 90 to be diverted into the descending aorta 98 and away from and not into the right subclavian artery 26, right carotid artery 12, left carotid artery 14 and left subclavian artery 28. Emboli 90 will not be capable of flowing through the left subclavian artery 28 as it would be blocked due to the presence, of the insertion device 58 with the occluding balloon 122 in the left subclavian artery 28. The third occluding balloon 122 can engage the outer surface of the insertion device 58 and can have an axis offset from the axes of the first and second occluding catheters 16, 20. Leaving the insertion device 58 within the left subclavian artery 28 during the time of inflation of the occluding balloons 18, 22 may cause the insertion device 58 to block emboli 90 from passing through the left subclavian artery 28 even without inflation of balloon 122, if the size of devise 58 is large enough to block the flow via the artery 28, however using an inflatable third balloon 122 would allow one to be able to use a significantly smaller size of an insertion device 58 and facilitate its insertion. As used herein and as previously discussed, “occlusion” of an artery may be when the balloon is in that artery and may be when the balloon is within an upstream artery thus occluding downstream flow to the artery in question.

The interruption of carotid flow or pulse may be assessed by angiography, carotid Doppler, or arterial pressure and waveform patterns distal to the level of occlusion in accordance with certain exemplary embodiments. In addition, percutaneous cerebral oximetery, electroencephalography and transcranial Doppler monitoring can be applied. In other arrangements, it may not be the case that this monitoring is applied in order to confirm positioning of the occluding balloons 18, 22, 120 and 122.

Once the position of the occluding balloons 18, 22, 122 and/or 120 is achieved the insertion device 58 may be pulled back into the lumen of the left subclavian artery 28. The insertion device 58 may be located in the left subclavian artery 28 during inflation and use of the apparatus 10. Alternatively, the insertion device 58 may be completely removed from the circulatory system 92 during use of the apparatus 10, or may remain within the aortic arch 96 during use of the apparatus 10.

Considering the fact that the length of most manipulations, associated with formation of cerebral emboli 90 rarely exceeds 1-2 minutes, a temporary interruption of the carotid flow for this period of time, plus 0.5-1.5 minutes to allow for complete washout of emboli 90 from the aorta 96 is completely safe and feasible. Thus, the time of interruption of flow through both carotid 12, 14 and subclavian arteries 26, 28 (if performed) should not exceed 1.5-3.5 minutes. This amount of time is usually sufficient to allow for complete washout of particulate matter and air from the heart 94, aortic valve 100, ascending aorta 102 and aortic arch 96 into descending aorta 98 and distal vasculature 110, 112 without inducing ischemic brain injury.

A manometer 106 may be in communication with the first distal opening 42, second distal opening 56, pressure measurement distal opening 76, and pressure measurement opening 132. The first proximal measurement port 40 and the second proximal measurement port 54 can be connected to the manometer 106. A pressure measurement line 114 can be provided and be connected to the manometer 106 and to the pressure measurement proximal opening 74. Measurement channel 133 can be connected to the manometer 106 as well and can be receive through the port 130 as is the third occluding balloon inflation channel 128. A pressure supply 88 is in communication with the first proximal inflation port 34, the second proximal inflation port 48 and the third inflation port 130, 134, 140 to provide inflation pressure for the first, second and third occluding balloons 18, 22, 122. An alarm system 86 is in communication with the pressure supply 88 and manometer 106. Should the physician or physician's assistant forget to deflate the occluding balloons 18, 22, 122 in a timely fashion, an alarm would go off and the occluding balloons 18, 22, 122 would deflate spontaneously to avoid undue interruption of the cerebral flow. The alarm could be also triggered by the occurrence of emboli 90 detected by transcranial Doppler 108 (also in communication with the alarm system 86) or any other means such as infrared cerebral spectroscopy, cerebral oximetry, electroencephalograpy or other means, thus indicating an urgent need for temporary occlusion of the cerebral flow. Here, the alarm system 86 will cause inflation of the occluding balloons 18, 22. The alarm system 86 along with deflation or inflation of the occluding balloons 18, 22, 122, 120 could be overridden by the physician when clinically indicated.

After deflation of the occluding balloons 18, 22, 122, 120 the procedure can be repeated if necessary once a 5-10 minute period of cerebral reperfusion is reached. After completion of the main surgical procedure the occluding catheters 16, 20 can be pulled back into the left subclavian artery 28 for subsequent removal.

Measurement of the pressure at the occluding balloons 18, 22, 120, 122 and at downstream areas from the occluding balloons 18, 22, 120, 122 via distal openings 42, 56 and for the third balloon 122—via distal openings 126 may improve the efficacy and safety of the carotid balloon occlusion. Thus, if the post-balloon occlusion pressure measured in the innominate artery 24, and carotid artery 14 drops more than 50% after the balloons 18, 22 are inflated, the occlusion of the arteries 12, 14 is complete. On the other hand once the intra-balloon pressure in balloons 18, 22, 120, 122 exceeds systemic arterial pressure of the patient (as could be measured via the distal openings 64, 70) one can assume that the balloon is occluding the respective artery.

On the other hand, the intra-balloon pressure during balloon 18, 22, 120, 122 inflation should not exceed by more than 10-50 mm Hg the patient's systemic arterial pressure in order to avoid an undue trauma to the arterial walls 24, 14, 26, 28. The intra-balloon 18, 22, 120, 122 inflation pressure may be greater than the patient's systemic arterial pressure by 10 mm Hg or more. In some exemplary embodiments the pressure of the occluding balloons 18 and 22 that causes their inflation may be up to but no greater than 60 mm of Hg.

The apparatus 10 and insertion device 58 may achieve adequate bilateral carotid flow interruption at the minimal degree of internal pressure on the carotid, innominate and subclavian artery walls 12, 14, 24, 26, 28 in order to minimize potential injury to these vessels. This goal should be achieved by low-pressure inflation of the occlusion balloons 18, 22, monitoring of the proximal and post-occlusion carotid arterial pressures. This may also be accomplished by comparing systemic arterial and occluding balloon 18, 22 pressures and trying to keep pressures in occlusion balloons 18, 22 only slightly higher than systemic arterial pressure.

Placement of the first occluding balloon 18 in the right carotid artery 12 may be done so that placement is not in the innominate artery 24. This arrangement may protect the right carotid artery 12, but not the right vertebral 152 circulation. This measure is sometimes necessary in patients with significant calcification and atherosclerotic changes of the innominate artery 24, precluding safe balloon occlusion of this vessel 24. With the left carotid artery 14 occluded by a second occluding balloon 22, this method will still provide significant cerebral protection by blocking the inflow of emboli 90 into carotid circulation bilaterally. In addition, temporary interruption of flow through both carotid arteries 12, 14 is expected to produce concomitant decrease of flow through both subclavian arteries 26, 28, thus decreasing the risk of cerebral emboli 90 via both carotid and vertebro-basilar pathways.

The apparatus 10 may be introduced into the circulatory system 92 in a variety of manners and it is to be understood that the disclosed embodiments are only exemplary. With reference to FIG. 19, the apparatus 10 does not include an insertion device 58, but it may be represented by a common shaft for two, three or more catheters in a branching pattern positioned according to disclosed optimal distances between each other to match the position of the ostia of the patient's arteries 12, 14, 24, 26, 28. The first occluding catheter 16 is introduced through the left subclavian artery 28 and into the right carotid artery 12 where the first occluding balloon 18 may be used to occlude the right carotid artery 12 and/or innominate artery 24, whereas the proximal occluding balloon 120 may occlude the left subclavian artery 28. This proximal occluding balloon 120 may be referred to as a fourth occluding balloon 120 and can be located on the same occluding catheter shaft 16 as the first occluding balloon 18. The second occluding catheter 20 may be introduced through the right subclavian artery 26 and moved into the left carotid artery 14 where the second occluding balloon 22 is inflated to occlude the left carotid artery 14 and a third occluding balloon 122 may occlude the right subclavian artery 26. The third occluding balloon 122 can be located on the same second occluding catheter 20 shaft as is the second occluding balloon 22. As such, the FIG. 19 embodiment features two occluding catheters 16, 20 that each carry two of the occluding balloons 18, 22, 120, 122. In other arrangements, the apparatus 10 may be inserted through the right subclavian artery 26 and not located at all in the left subclavian artery 28. When this is done, the first occluding catheter 16 may be advanced into the left carotid artery 14, the second occluding catheter 20 may be advanced into the innominate artery 24 or the right carotid artery 12 and the third occluding balloon 122 of the device 58 may be inflated within the right subclavian artery 26. With reference to FIG. 20, the apparatus 10 has inseretion device 58 and may be introduced through the left femoral artery 112 and advanced into the aortic arch 96 such that no portion of the insertion device 58 is located in the right or left subclavian artery 26, 28. In this arrangement, emboli 90 may move through both the right and left subclavian arteries 26, 28, however if the occluding balloon 18 is positioned in the innominate artery 24, while the occluding balloon 22 is positioned in the carotid artery 14, while the third occluding balloon 120 is positioned in the left subclavian artery 28, the emboli 90 will be totally deflected from the brain and the risk of embolic stroke will be significantly less. The third occluding balloon 120 is on a catheter shaft that exits the insertion device 58 from an opening of the insertion device 58 that is located proximal to both the first distal opening 64 and the second distal opening 70. The third occluding catheter 21 extends through a third occluding catheter channel 135 of the insertion device 58. The third occluding catheter channel 135 extends from the aforementioned opening to the port 140. A syringe or other device (not shown) can be used to inflate and deflate the third occluding balloon 120.

The apparatus may thus achieve simultaneous occlusion of both carotid arteries 12, 14. However, in some arrangements one of the occluding balloons 18 may be actuated first to occlude one of the carotid arteries 12, 14, while subsequently the other occluding balloon 22 can be actuated to occlude the other one of the carotid arteries 12, 14. The anatomy of the aortic arch 96 and the take off points of the innominate artery 24 and left carotid artery 14 can be estimated by preoperative computerized angiography and intraoperative aortography, however using disclosed ranges of distances between distal openings 64, 70 and a third occluding balloon 122, or 120 of the device 58 may obviate the need for these measurements in each particular patient. As a result, the distal openings 64, 70 and a third occluding balloon 122 can be advanced into the aortic arch 96 to correspond anatomically to the orifices of the innominate artery 24, the left carotid artery 14 and the left subclavian artery 28. The occluding balloons 18, 22, 120 can be fully or partially inflated once they have exited the insertion device 58, whereas the occluding balloon 122 that is carried by the insertion device 58 can be inflated once the insertion device 58 is positioned and the balloon area (designed by the cross-section line 13-13 in FIG. 12) reaches the ostium of the left subclavian artery 28.

The occluding catheters 16 and 20 may be wireless in that they can be placed within the patient without the use of a guide wire 118. The occluding balloons 18, 22, 120, 122 can be arranged so that when inflated all of the blood into the artery in question (12, 14, 26, 24, and/or 28) is blocked. In this regard, no blood flows past the inflated balloons 18, 22 or the insertion device 58. The arteries 12, 14, 26, 24, and/or 28 may be completely prevented from having blood flowing through them as per the arrangement of all portions of the apparatus 10. In other arrangements, the occluding balloons 18, 22 are arranged so that some blood does flow into arteries 12, 14, 26, 24, and/or 28. The occluding balloons 18, 22 can be partially inflated but not inflated all the way to seal the arterial wall. The occluding balloons 18, 22 can be made so that even if fully inflated they are small enough not to completely block blood flow to seal the arterial wall. Some amount of blood can in fact flow past the inflated balloons 18, 22 and into the various arteries 12, 14, 26, 24, and/or 28. The blood that flows past is unfiltered blood. Although emboli 90 may still flow into cerebral circulation and cause stroke, even partial reduction of flow will cause a partial reduction in the chance of stroke or the severity of stroke. The apparatus 10 with or without insertion device 58 may block from 30%-50%, from 50%-70%, from 70%-90% or up to 100% of the blood flow into the various arteries 12, 14, 26, 24, and/or 28 in accordance with certain exemplary embodiments. Blood that does flow into the various arteries 12, 14, 26, 24, and/or 28 comes directly from the aortic arch 96 and is unfiltered and may contain emboli 90. A filtering mesh may or may not be employed in the present apparatus 10. As used herein, the term “occlude” is broad enough to include complete blockage of blood flow and to include partial blockage of blood flow while still allowing some unfiltered blood to flow through. Also, as used herein when referring to a “block” of blood flow, it is to be understood that this term is broad enough to cover complete blocking of blood flow and partial blocking of blood flow such that some amount of unfiltered blood flows through.

In use, the occluding catheters 16, 20 and device 58 may be used so that partial inflation or total inflation of the occluding balloons 18, 22, 120, 122 is made during a medical procedure to control the blood flow through by reducing the risk of stroke while still allowing blood to enter the cerebral circulation. When fully inflated to completely block blood flow, the occluding balloons 18, 22 are solid components and not filters and do not filter emboli 90 but rather prevent everything including blood and emboli 90 from moving therethrough. The occluding balloons 18, 22, 120, 122 may completely block blood and emboli 90 from moving through the particular blood vessel such that no blood or emboli 90 flows through the tube sections of the occluding catheters 16, 20 and device 58 past the occluding balloons 18, 22, 120, 122. The occluding balloons 18, 22, 120, 122 and the tubular sections of the occluding catheters 16, 20 and insertion device 58 located at the blocked area of blood/emboli 90 flow when positioned are not porous members and do not filter any blood. However, when the occluding balloons 18, 22, 120, 122 are deflated partially deflated, or fully inflated but less than the diameter of the vessel they are in allow blood and emboli 90 to flow around them through the particular blood vessel and they are not filtered in any manner, although the flow rate may be decreased due to the presence of the occluding balloons 18, 22, 120, 122 and tubular sections of the occluding catheters 16, 20 and insertion device 58.

While the present invention has been described in connection with certain preferred embodiments, it is to be understood that the subject matter encompassed by way of the present invention is not to be limited to those specific embodiments. On the contrary, it is intended for the subject matter of the invention to include all alternatives, modifications and equivalents as can be included within the spirit and scope of the following claims. 

What is claimed:
 1. An apparatus for preventing stroke by occluding blood flow to arteries of a patient, comprising: a first occluding catheter that carries a first occluding balloon that has an inflated configuration that occludes either a right carotid artery or a left carotid artery; a second occluding catheter that carries a second occluding balloon that has an inflated configuration that occludes the other one of the right carotid artery or the left carotid artery that is not occluded by the first occluding balloon; and a third occluding balloon that has an inflated configuration that occludes either a right or left subclavian artery.
 2. The apparatus as set forth in claim 1, wherein the first occluding balloon is in the inflated configuration and is located in an innominate artery of the patient and occludes flow to the right carotid artery and the right subclavian artery of the patient, wherein the second occluding balloon is in the inflated configuration and is located in the left carotid artery and occludes flow to the left carotid artery and wherein the third occluding balloon is in the inflated configuration and is located in the left subclavian artery and occludes flow to the left subclavian artery and a left vertebral artery.
 3. The apparatus as set forth in claim 1, wherein the first occluding balloon is in the inflated configuration and is located in the right carotid artery and occludes the right carotid artery and does not occlude the right subclavian artery of the patient, and wherein the second occluding balloon is in the inflated configuration and is located in the left carotid artery and occludes the left carotid artery and wherein the third occluding balloon is in the inflated configuration and is located in the right subclavian artery and occludes the right subclavian artery; and further comprising a fourth occluding balloon that has an inflated configuration and that is in the inflated configuration and is located in the left subclavian artery and occludes the left subclavian artery; and wherein at least two of the first, second, third and fourth occluding balloons share a common catheter shaft.
 4. The apparatus as set forth in claim 1, wherein the first occluding catheter has a first occluding catheter shaft, wherein a first inflation channel is defined by the first occluding catheter shaft, wherein the first inflation channel extends from a first proximal inflation port to a first occluding balloon opening; wherein the second occluding catheter has a second occluding catheter shaft, wherein a second inflation channel is defined by the second occluding catheter shaft, wherein the second inflation channel extends from a second proximal inflation port to a second occluding balloon opening; and wherein the third occluding balloon is carried by a third occluding catheter, wherein the third occluding catheter has a third occluding catheter shaft, wherein a third inflation channel is defined by the third occluding catheter shaft.
 5. The apparatus as set forth in claim 4, wherein: the first occluding catheter shaft defines a first pressure measurement channel that extends from a first proximal measurement port to a first distal opening; wherein the second occluding catheter shaft defines a second pressure measurement channel that extends from a second proximal measurement port to a second distal opening; and wherein the third inflation channel extends from a third proximal inflation port to a third occluding balloon opening, wherein the third occluding catheter shaft defines a third pressure measurement channel that extends from a third proximal measurement port to a third distal opening.
 6. The apparatus as set forth in claim 4, further comprising an insertion device that defines a first occluding catheter channel that extends from an insertion device first proximal opening to an insertion device first distal opening, wherein the first occluding catheter is located in the first occluding catheter channel and wherein the first occluding balloon is located outside of the first occluding catheter channel; wherein the insertion device defines a second occluding catheter channel that extends from an insertion device second proximal opening to an insertion device second distal opening, wherein the second occluding catheter is located in the second occluding catheter channel and wherein the second occluding balloon is located outside of the second occluding catheter channel; wherein the insertion device defines a third occluding catheter channel that extends from an insertion device third proximal opening to an insertion device third distal opening, wherein the third occluding catheter is located in the third occluding catheter channel and wherein the third occluding balloon is located outside of the second occluding catheter channel.
 7. The apparatus as set forth in claim 1, further comprising an insertion device that defines a first occluding catheter channel that extends from an insertion device first proximal opening to an insertion device first distal opening, wherein the first occluding catheter is located in the first occluding catheter channel; wherein the insertion device defines a second occluding catheter channel that extends from an insertion device second proximal opening to an insertion device second distal opening, wherein the second occluding catheter is located in the second occluding catheter channel; wherein the third occluding balloon is located on the insertion device, and wherein the insertion device defines a third occluding balloon inflation channel that extends from an insertion device proximal inflation port to the third occluding balloon opening, wherein the third occluding balloon is located on an outer surface of the insertion device and is proximal to the first and second distal openings of the insertion device.
 8. The apparatus as set forth in claim 7, wherein the insertion device defines a pressure measurement channel that extends from a pressure measurement proximal opening to a pressure measurement distal opening, wherein the pressure measurement channel is not in fluid communication with the first occluding catheter channel and is not in fluid communication with the second occluding catheter channel.
 9. The apparatus as set forth in claim 1, wherein the first occluding balloon is in the inflated configuration and wherein the second occluding balloon is in the inflated configuration, wherein the first occluding balloon has a first diameter and wherein the second occluding balloon has a second diameter, and wherein the first diameter is from 50%-100% larger than the second diameter.
 10. The apparatus as set forth in claim 1, further comprising: a first syringe in fluid communication with the first occluding balloon, wherein the first syringe pushes air or fluid into the first occluding balloon and inflates the first occluding balloon to the inflated configuration; a second syringe in fluid communication with the second occluding balloon, wherein the second syringe pushes air or fluid into the second occluding balloon and inflates the second occluding balloon to the inflated configuration; and a third syringe in fluid communication with the third occluding balloon, wherein the third syringe pushes air or fluid into the third occluding balloon and inflates the third occluding balloon to the inflated configuration.
 11. The apparatus as set forth in claim 1, further comprising an alarm system that activates a pressure supply to the first occluding balloon, the second occluding balloon and the third occluding balloon to inflate the first occluding balloon, the second occluding balloon and the third occluding balloon to the inflated configurations when microemboli are detected by the alarm system, wherein the alarm system deflates the first and second occluding balloons from the inflated configurations when the first, second and third occluding balloons have remained in the inflated configurations for a cut-off period of time, and wherein the alarm system has a manual override to prevent inflation and deflation by the alarm system.
 12. An apparatus for preventing stroke by occluding blood flow through a right carotid artery and a left carotid artery of a patient, comprising: an insertion device that defines a first occluding catheter channel a second occluding catheter channel and a third occluding balloon inflation channel, wherein the insertion device has a third occluding balloon; a first occluding catheter that carries a first occluding balloon that has an inflated configuration that occludes either the right carotid artery or the left carotid artery, wherein the first occluding catheter is located in the first occluding catheter channel and is movable through the first occluding catheter channel such that the first occluding catheter is movable relative to the insertion device; and a second occluding catheter that carries a second occluding balloon that has an inflated configuration that occludes the other one of the right carotid artery or the left carotid artery that is not occluded by the first occluding balloon, wherein the second occluding catheter is located in the second occluding catheter channel and is movable through the second occluding catheter channel such that the second occluding catheter is movable relative to the insertion device and is movable relative to the first occluding catheter.
 13. The apparatus as set forth in claim 12, wherein the insertion device has an insertion device first proximal opening from which the first occluding catheter channel extends to an insertion device first distal opening of the insertion device, wherein the insertion device has an insertion device second proximal opening from which the second occluding catheter channel extends to an insertion device second distal opening of the insertion device, wherein the insertion device has an insertion device third proximal opening from which a third occluding balloon inflation channel extends to a third distal opening of the insertion device to the third occluding balloon; wherein the first occluding balloon is located outside of the first occluding catheter channel and is in the inflated configuration and is located in either the right carotid artery or an innominate artery and completely blocks blood flow through the right carotid artery, wherein the second occluding balloon is located outside of the second occluding catheter channel and is in the inflated configuration and is located in and completely blocks blood flow through the left carotid artery, and wherein the, third occluding balloon is located on an outer surface of the insertion device and is in the inflated configuration and is located in and completely blocks blood flow through a subclavian artery.
 14. The apparatus as set forth in claim 12, wherein the insertion device defines a pressure measurement channel that extends from a pressure measurement proximal opening to a pressure measurement distal opening, wherein the pressure measurement channel is not in fluid communication with the first occluding catheter channel and is not in fluid communication with the second occluding catheter channel; and wherein the insertion device defines a third balloon inflation channel that extends from a third occluding balloon inflation port of the insertion device and ends at third balloon inflation openings of the insertion device.
 15. The apparatus as set forth in claim 12, wherein the first occluding catheter has a first inflation channel that extends from a first occluding balloon opening to a first proximal inflation port, wherein the first occluding catheter has a first pressure measurement channel that extends from a first distal opening to a first proximal measurement port, wherein the first inflation channel is not in fluid communication with the first pressure measurement channel, and wherein the first distal opening is located distal to the first occluding balloon opening; wherein the second occluding catheter has a second inflation channel that extends from a second occluding balloon opening to a second proximal inflation port, wherein the second occluding catheter has a second pressure measurement channel that extends from a second distal opening to a second proximal measurement port, wherein the second inflation channel is not in fluid communication with the second pressure measurement channel, and wherein the second distal opening is located distal to the second occluding balloon opening; and wherein the third inflation channel extends from a third occluding, balloon inflation channel opening to a third occluding balloon inflation port.
 16. The apparatus as set forth in claim 12, wherein the insertion device defines a first distal opening having a cradle space sufficient to accommodate the first occluding balloon in a deflated folded state, and wherein the insertion device defines a second distal opening having a cradle space sufficient to accommodate the second occluding balloon in a deflated folded state.
 17. The apparatus as set forth in claim 16, wherein the first and second occluding balloons are not passed through the first and second occluding balloon channels and are prepackaged into the cradle spaces of the first and second distal openings of the insertion device.
 18. The apparatus as set forth in claim 16, wherein the cradles of the first distal opening and second distal opening are shaped and slanted relative to a majority of the cross-section of the first and second occluding catheter channels to achieve a congruent approximation with the deflated/folded first and second occluding balloons.
 19. The apparatus as set forth in claim 12, wherein the distance between a. first distal opening, a second distal opening and the third occluding balloon of the insertion device closely approximates the distances between an innominate artery, the left carotid artery and the left subclavian artery and ranges between 0.5 centimeters and 8.5 centimeters.
 20. A method of diverting emboli from cerebral circulation, comprising: positioning a first occluding catheter within a circulatory system of a patient; positioning a second occluding catheter within the circulatory system of the patient, wherein the second occluding catheter is moved independently from the first occluding catheter; positioning a third occluding catheter that has a third occluding balloon or an insertion device carrying the third occluding balloon within a circulatory system of the patient; inflating a first occluding balloon of the first occluding catheter; inflating a second occluding balloon of the second occluding catheter; inflating the third occluding balloon of the third occluding catheter or the insertion device; wherein the inflated first occluding balloon , the inflated second occluding balloon, and the inflated third occluding balloon occlude a flow to: (1) the left carotid artery; (2) the left subclavian artery; (3) (the right carotid artery) or(right carotid artery and right subclavian artery via occlusion of the innominate artery).
 21. The method as set forth in claim 20, further comprising positioning the insertion device within the circulatory system of the patient, wherein the step of positioning the first occluding catheter involves not moving the first occluding balloon through the insertion device such that the first occluding balloon is pre-packaged and pre-positioned inside a cradle of a first distal opening of the insertion device, wherein the step of positioning the second occluding catheter does not involve moving the second occluding balloon through the insertion device such that the second occluding balloon is pre-packaged and pre-positioned inside a second distal opening of the insertion device.
 22. The method as set forth in claim 20, wherein the first occluding balloon is at least partially inflated before being positioned within the right carotid artery and/or innominate artery of the patient, and wherein the second occluding balloon is at least partially inflated before being positioned within the left carotid artery of the patient.
 23. The method as set forth in claim 20, further comprising: measuring pressure of the circulatory system at a location distal from the first occluding balloon after inflation of the first occluding balloon; and measuring pressure of the circulatory system at a location distal from the second occluding balloon after inflation of the second occluding balloon, wherein the location distal from the second occluding balloon is a different location than the location distal from the first occluding balloon.
 24. The method as set forth in claim 20, wherein the first occluding balloon is located in an innominate artery of the patient and is not located in the right carotid artery of the patient, wherein the first occluding balloon is inflated and completely blocks blood flow to the right carotid and right vertebral arteries, wherein the second occluding balloon is located in the left carotid artery and is inflated and completely blocks blood flow to the left carotid artery; and wherein the third occluding balloon is located in the left subclavian artery and is inflated and completely blocks the flow to the left vertebral artery.
 25. The method as set forth in claim 20, wherein the first occluding balloon is located in the right carotid artery of the patient and is inflated and completely blocks blood flow through the right carotid artery, wherein the second occluding balloon is located in the left carotid artery and is inflated and completely blocks blood flow through the left carotid artery. 